射血分数保留的心力衰竭伴高血压患者如何管理,看这篇就够了!

2021-10-22 MedSci原创 MedSci原创

射血分数保留的心力衰竭(HFpEF)在临床上约占50%,然而,HFpEF病因复杂,精准诊断相对困难。近期,根据HFpEF不同表型进行分类,高血压同样被认为是血 管疾病相关的HFpEF的重要病因。

射血分数保留的心力衰竭(HFpEF)在临床上约占50%,然而,HFpEF病因复杂,精准诊断相对困难。近期,根据HFpEF不同表型进行分类,高血压同样被认为是血 管疾病相关的HFpEF的重要病因。

那么,HFpEF伴高血压患者的发病机制、诊治原则、降压目标和药物合理应用有哪些不同,本文整理了《射血分数保留的心力衰竭伴高血压患者管理中国专家共识》(以下简称共识)最新证据指导,以分享给各位同道。

HFpEF伴高血压的发病机制

HFpEF伴高血压患者的早期表现包括左心室充 盈、扩张及舒张功能异常。由于动脉压升高和外周阻 力增加导致心室后负荷增加,引起左心室向心性肥厚 (左心室质量增加而心室容量下降),心室的顺应性降,从而引起舒张功能障碍。

高血压常合并动脉粥样硬化疾病,而发生左心室肥厚的患者需要更高的心 肌氧供,从而引起心肌缺血和纤维化改变,进一步加重左心室舒张功能障碍。目前有研究认为,收缩功能障碍也在高血压向HFpEF的进展中起到一定作用。

此外,高血压激活肾素血管紧张素醛固酮系统(RAAS)及交感神经系统同样起到一定的作用。RAAS通过增加内皮素、转化生长因子β、肿瘤 生长因子α等的活性,促进心肌细胞肥大及心室肥厚, 通过诱导血管重建增加后负荷并导致心室进一步肥厚。在此基础上,RAAS还可刺激成纤维细胞肥大并 诱导胶原沉积,最终促进心肌纤维化。交感神经系统长时间激活可通过诱导心肌细胞凋亡促进心力衰竭的进展,产生心血管效应,如心率、心肌收缩力增加,静脉容量减少及外周阻力增加,并最终导致心室重构及功能障碍。

HFpEF伴高血压的诊断

对于考虑有HFpEF伴高血压的患者,推荐根据《中国高血压健康管理规范(2019)》对高血压进行系统的病因鉴别诊断、危险因素及靶器官损害评估,主要包括收集患者详细的病史(症状、病程、降压药治疗、既往史及家族史等)、体格检查、 相关实验室检查(血生化、尿液分析、糖化血红蛋白、甲状腺功能等)、心电图检查、动态血压监测、颈动脉超声、眼底检查、胸部X线摄片、肢体动脉检测、超声心动图检查等。

图:HFpEF伴高血压诊疗流程图

HFpEF伴高血压的治疗

HFpEF伴高血压的治疗,包括病因治疗和药物治疗。由于HFpEF病理生理特征多种多样,它们与不同的病因相关,包括伴发的 心血管病(如心房颤动、高血压、冠状动脉粥样硬化性心脏病、肺动脉高压)和非心血管病(如糖尿病、慢性肾脏病、贫血、慢性阻塞性肺疾病和肥胖等)。

在药物治疗中,若有容量负荷过重的临床表现,建议用利尿剂改善充血,从而改善心力衰竭的症状和体征。对于有明显液体潴留的患者,本共识建议首选襻利尿剂如呋噻米、托拉塞米等;对于顽固性水肿或低钠血症者,托伐普坦疗效显著,推荐用于常规利尿剂治疗效果不佳、有低钠血症或肾功能损害倾向的患者。

此外,血管紧张素受体脑啡肽酶抑制剂(ARNI)、血管紧张素转换酶抑制药 ACEI)和血管紧张素受体阻滞药(ARB)在治疗HFpEF伴高血压时起到重要作用。对于HFpEF伴高血压患者,鉴于ARNI的降压疗效和器官保护作用,共识推荐用ARNI以降低心血管病死亡和再入院风险。

ACEIARB通过阻抑RAAS活性,抑制血管紧 张素1型(AT1)受体活化, 进而 HFrEF患者中降低心血管事件的发生率。钙通道阻滞剂 CCB) CCB 广泛用于高血压的治疗。对于HFpEF伴高血压的患者,既往没有研究表明 CCB是否带来获 益抑或增加风险。由于二氢吡啶类 CCB降压效果强, 对于血压控制不佳的 HFpEF 患者,相关指南建议联 合二氢吡啶类 CCB控制血压。

HFpEF伴高血压血压管理目标

HFpEF血压管理的目的是降低心血管事件发生率。目前指南对于高血压人群的管理 目标为14090mm Hg,不管是否合并有心力衰竭。既往研究显 示,对于高血压患者,控制收缩压<140mm Hg可以 减低27%新发心力衰竭风险。对于合并HFpEF的患者,具体血压目标值并没有随机对照试验来证实。 观察性研究表明心力衰竭患者的收缩压及全因死亡和 心力衰竭再入院呈反J型曲线的关系;HFpEF患者全因死亡风险的理想血压值在12873mm Hg,过 高与过低的血压都与不良的心血管事件相关。根据目 前血压管理指南,本共识建议对所有血压升高或高血 压的成年人进行药物干预,对于需要药物治疗的一般 高血 14090,理 为<13080,但不能低于12070mm Hg。未来仍 需进一步探索HFpEF 标值。

HFpEF伴高血压的预防

HFpEF伴高血压常合并其他心血管病危险因素 如血脂异常、糖尿病、吸烟、肥胖、高尿酸血症等。在控 制高血压的同时,也应控制其他危险因素,以降低心力衰竭发 病率及心血管事件。

血脂异常:血脂异常与冠状动脉粥样硬化性 疾病关系明确,目前指南推荐对冠心病患者或冠心病 高危人群,用他汀类药物治疗。

糖尿病:糖尿病是心力衰竭发生的独立预测因素,且女性糖尿病患者较男性更容易患心力衰竭。胰岛素抵抗引起的游离脂肪酸在心脏组织中贮积,导致线粒体功能障碍,从而影响心功能。血糖管理应依据目前糖尿病指南。钠-葡萄糖协同转 运蛋白2(SGLT2)抑制剂相关研究显示对2型糖尿病患者有心血管保护作用。

肥胖:肥胖是新发心力衰竭和心力衰竭不良预后的危险因素,体质量指数与心力衰竭全因死亡风险呈U型关系,体质量过轻和过度肥胖均为心力衰 竭预后不良的危险因素。对于过度肥胖的患者,建议生活方式干预仍是减肥的基础,药物治疗和减肥手术可作为管理肥胖的辅助手段。

其他危险因素,包括吸烟、高尿酸血症等同样是心力衰竭发生的危险因素。应对这些危险因素综合管理,在控制高血压的同时,控制体质量、戒烟、健康膳食、适当运动减低心力衰竭患病风险。

参考来源

射血分数保留的心力衰竭伴高血压患者管理中国专家共识编写委员会.射血分数保留的心力衰竭伴高血压患者 管理中国专家共识.中华高血压杂志2021年7月第29卷第7期

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    2022-01-30 ms5000000031923401

    马住

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    2021-10-23 查查佳佳

    睡眠障碍可能是导致这种风险的一个未确

    0

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    2021-10-22 ms6000000710651942

    学到了

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